Antibiotic-resistant gram-positive cocci: implications for surgical practice

Gram-positive infections are causing more serious infections than ever before in surgical patients, who are increasingly aged, ill, and debilitated. Invasive procedures disrupt natural barriers to bacterial invasion, and indwelling catheters may act as conduits for infection. The use of broad-spectrum antibiotics selects for the emergence of resistant pathogens. Potential sites of nosocomial gram-positive infections include the urinary tract, surgical site (including prosthetic devices), intravascular loci, lung and pleural space, facial sinuses, and peritoneal cavity. Responsible organisms include species from the genera Enterococcus and Staphylococcus. Methicillin-resistant strains of Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) emerged during the 1970s, leading to a marked increase in the use of vancomycin as the treatment of choice. Vancomycin use, in turn, has been implicated (along with widespread cephalosporin use) in the emergence of vancomycin-resistant enterococci (VRE) during the 1990s. Of great concern is the likely emergence of vancomycin-resistant staphylococci, which would constitute a public health emergency. Vancomycin remains the treatment of choice for infections caused by MRSA/MRSE, but rampant inappropriate use (e.g., prophylaxis in non-penicillin-allergic patients, treatment of methicillin-sensitive strains) must be curtailed. Chloramphenicol is increasingly the treatment of choice for serious VRE infections. Infection control policy must also minimize the possibility of transmission. All infected or colonized patients should be isolated and all environmental surfaces considered contaminated. Disposable gloves are mandatory for all patient contact, even incidental contact, and must be disposed of after each patient encounter. Hand-washing (the single most effective infection control measure) is mandatory after glove disposal. Gowns should be worn for direct contact with infected patients and masks used when aerosolization or splashing of secretions is likely.